EP551 - Differences in Outcomes and Cost for Proctectomy Across the United States by Hospital Ownership Status

Purpose/Background: The corporatization of healthcare has shifted the landscape of hospital ownership. The effects of this transition on rectal surgical quality are largely unknown. Proctectomy represents a high-risk procedure that has been shown to have a volume-outcome relationship, with published minimum hospital volume thresholds set at 16. We aimed to assess differences in clinical and economic outcomes of patients undergoing proctectomy at for-profit (FP) versus non-profit (NP) hospitals across the United States to determine differences in surgical quality.

Methods/Interventions: A retrospective observational analysis of adult patients undergoing proctectomy for anal or rectal neoplasms, 2016-2021, within the Healthcare Cost and Utilization Project database from FL, IA, UT, and WI was performed. Hospital ownership status and inflation-adjusted hospital-specific cost-to-charge ratios were abstracted from the American Hospital Association database. If hospitals performed ≥ 16 proctectomies in a year, they were designated high volume (HV) hospitals in that year. We used multivariate regression to compare differences in index hospitalization mortality, length of stay (LOS), cost per day, non-routine discharge, and 30-day readmission stratified by profit status. A subgroup analysis was performed among HV hospitals.

Results/Outcomes: A total of 10,493 patients with anal or rectal neoplasms underwent proctectomy at 270 hospitals, with 1,949 (18.6%) receiving care at FP hospitals. Most patients had a primary rectal pathology (n=10,258, 97.8%). A greater proportion of patients treated at FP hospitals underwent urgent/emergent proctectomies compared to patients treated at NP hospitals (27.8% vs. 10.8%, p< 0.001). Patients treated at FP hospitals more frequently had Medicare (55.2% vs. 44.4%, p< 0.001) and were less likely to have private insurance (33.0% vs. 44.0%, p< 0.001). There were similar rates of open and minimally invasive (MIS) proctectomies performed (FP open: 58% vs. NP open: 56%, p=0.16; FP MIS: 42% vs. NP MIS: 45%, p=0.16). On unadjusted analysis, FP hospitals had a greater rate of mortality (1.28% vs. 0.56%, p=0.001), median length of stay (5 [4,9] vs. 5 [3,8] days, p< 0.001), 30-day readmission (23.9% vs. 19.2%, p< 0.001), and lower median cost per day ($3,208 [$2,353, $4,745] vs. $4,197 [$2,922, $6,113], p< 0.001). After adjustment, FP hospitals maintained a lower cost per day (difference $-1,879 [$-2,768,-$-990]. A total of 49 hospitals met the volume quality threshold in at least one year (FP=10, NP=39). Patients treated at HV-FP hospitals had greater unadjusted LOS and rates of non-routine discharge, and lower cost per day compared to those at HV-NP hospitals (Table 1). After adjustment, significant differences in rates of non-routine discharge and cost per day persisted.

Conclusion/Discussion: We demonstrate similar clinical outcomes with lower cost per day for all patients undergoing proctectomy when obtaining care at FP vs. NP hospitals. Nonetheless, few centers met volume quality thresholds, with HV-FP hospitals offering lower cost per day with greater discharge to non-routine locations. This highlights an ongoing need for centralization of anal and rectal cancer care and the potential offsetting of cost to the post-acute care setting for FP centers.

Unadjusted and Adjusted Proctectomy Outcomes By Hospitals Ownership Status For High Volume Hospitals